Healthcare Provider Details

I. General information

NPI: 1821061482
Provider Name (Legal Business Name): STEVEN ERIC BENNETT D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

IV. Provider business mailing address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-1428
  • Fax: 505-212-1087
Mailing address:
  • Phone: 505-363-1428
  • Fax: 505-212-1087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDOM887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: